1. HIV/AIDS & STI Policy Guideline Clinical Management of Sexually Transmissible Infections DRAFT - 20 April 2001 FLOWCHARTS DEPARTMENT OF HEALTH Republic of South Africa

2. Patient complains of urethral discharge or dysuria Take history and Examine. Milk urethra if necessary Discharge confirmed? Ulcer(s) present? No Yes Use appropriate flow chart No Yes Urethral discharge / Burning on micturition (BOM) in men (Confirmed cases - code URD) Educate and counsel Promote and provide condoms Offer HIV counselling and testing if both facilities are available Review if symptoms persist Treat for gonorrhoea and chlamydia Educate Counsel if needed Promote and provide condoms Offer HIV counselling and testing if both facilities are available Partner management Advise to return in 7 days if symptoms persist Figure 1

3. Patient complains of persistent/recurrent urethral discharge or dysuria Discharge confirmed? Ulcer(s) present? No Use appropriate flow chart Yes No Treat for Trichomonas vaginalis Educate Counsel Promote and provide condoms Partner management Return in 7days Persistent/Recurrent urethral discharge in men Does history confirm re- infection or poor compliance? Yes Repeat urethral discharge treatment YesImproved? Refer No Figure 2 Educate and counsel Promote and provide condoms Offer HIV counselling and testing if both facilities are available Educate and counsel Promote and provide condoms Offer HIV counselling and testing if both facilities are available NB.: This flowchart assumes effective therapy for Gonorrhoea and Chlamydia to have been received and taken by the patient prior to this consultation Take history and Examine. Milk urethra if necessary

4. Patient complains of genital sore or ulcer Take history and examine Sore/Ulcer/Vesicle present? Educate and counsel Promote and provide condoms Offer HIV counselling and testing if both facilities are available Treat for syphilis and chancroid Educate Counsel on risk reduction Promote and provide condoms Offer HIV counselling and testing if both facilities are available Partner management Advise to return in 7 days Refer if necessary Yes No Genital ulcers (Confirmed cases - code GUD) Vesicles or small ulcers with history of recurrent vesicles? No Herpes simplex management Educate Counsel on risk reduction Promote and provide condoms Offer HIV counselling and testing if both facilities are available : Needs adaptation to local epidemiological situation Figure 3

5. Patient complains of inguinal swelling Take history and Examine Inguinal/femoral bubo(s)present? Treat for lymphogranuloma venereum and chancroid If fluctuant aspirate through healthy skin Educate on treatment compliance Counsel on risk reduction Promote and provide condoms Partner management Offer HIV counselling and testing if both facilities are available Advise to return for review in 7 days, and continue treatment If worse refer for further specialist opinion No Yes Inguinal bubo (Confirmed cases without ulcer - code BUB) Ulcer(s) present? No Yes Use genital ulcer flowchart Figure 4 Educate and counsel Promote and provide condoms Offer HIV counselling and testing if both facilities are available Any other STI present? Use appropriate flowchart No Yes

6. Take history and examine Swelling/pain confirmed? Testis rotated or elevated, or history of trauma? Treat for gonorrhoea and chlamydia Educate Counsel if needed Promote and provide condoms Partner management Offer HIV counselling and testing if both facilities are available Review in 7 days or earlier if necessary, if worse, refer No Reassure patient and educate Provide analgesics, if necessary Promote and provide condoms Offer HIV counselling and testing if both facilities are available No Refer immediately for a surgical opinion Scrotal swelling (Confirmed cases - code EPO) Patient complains of scrotal swelling/pain Yes Figure 5

7. Patient complains of vaginal discharge or vulval itching/burning Take history, examine patient and assess risk Educate Counsel Promote and provide condoms Offer HIV counselling and testing if both facilities are available Use flowchart for Lower Abdominal Pain Vaginal Discharge (Confirmed cases - code PVD) Yes No Yes Lower abdominal tenderness? Treat for bacterial vaginosis and trichomonas Treat for chlamydia trachomatis, gonococcal infection, bacterial vaginosis and trichomonas Treat for Candida Albicans Vulval oedema/curd like discharge Erythema, Excoriations present? Was risk assessment positive? No Yes No Educate Counsel Promote and provide condoms Offer HIV counselling and testing if both facilities are available : Needs adaptation to local social and behavioural epidemiological situation Figure 6 Abnormal discharge present?

8. Take history, examine patient (external, speculum and bimanual) and assess risk Educate Counsel Promote and provide condoms Offer HIV counselling and testing if both facilities are available Use flowchart for Lower Abdominal Pain Vaginal Discharge (speculum & bimanual) Yes No Yes Lower abdominal tenderness or cervical motion tenderness? Treat for bacterial vaginosis and trichomonas Treat for chlamydia trachomatis, gonococcal infection, bacterial vaginosis and trichomonas Treat for Candida Albicans Vulval oedema/curd like discharge Erythema, Excoriations present? Was risk assessment positive OR cervical mucopus detected? No Yes No Educate Counsel Promote and provide condoms Offer HIV counselling and testing if both facilities are available : Needs adaptation to local epidemiological situation Figure 7 Abnormal discharge present? Patient complains of vaginal discharge or vulval itching/burning

9. Patient complains of vaginal discharge or vulval itching/burning Examine patient (speculum and bimanual) and perform wet mount/gram stain microscopy of vaginal specimen Vaginal Discharge (speculum & microscope) Was risk assessment positive? Yes Figure 8 Treat for chlamydia trachomatis and gonococcal infection plus vaginal infection according to speculum and microscope examination findings Motile trichomonads in wet mount pH>4.5 KOH negative Clue cells seen pH>4.5 KOH positive Mucus from cervix Budding yeasts or pseudohyphae seen pH  4.5 KOH negative Cervical motion tenderness present? Treat for Candida albicans Treat for trichomonas vaginalis Treat for Bacterial vaginosis Treat for chlamydia trachomatis and gonococcal infection No findings Take history, examine patient (external) and assess risk Educate; Counsel; Promote and provide condoms; Partner management and, Offer HIV counselling and testing if both facilities are available, return if necessary Needs adaptation to local epidemiological situation Use flowchart for Lower Abdominal Pain Notes: 1. KOH Test: 1 drop 10% KOH to reveal the amine odour (fishy) 2. Wet mount: smear on slide with 1 drop of saline and view at 400X No

10. Is there cervical excitation tenderness or lower abdominal tenderness and vaginal discharge? Patient complains of lower abdominal pain Take history (including gynaecological) and examine (abdominal and vaginal) Any of the following present? Missed/overdue period Recent delivery/abortion/miscarriage Abdominal guarding and/or rebound tenderness Vaginal bleeding Yes Refer patient for surgical or gynaecological opinion and assessment. Before referral set up an IV line and apply resuscitatory measures if necessary No Manage for PID Review in 3 days No Lower abdominal pain (Confirmed cases - code PID) Patient has improved?NoRefer patient Yes Continue treatment until completed Educate/counsel Offer HIV counselling and testing if both facilities are available Any other illness found? Yes Manage appropriately Figure 9

11. Neonate with eye discharge Take history and examine Bilateral or unilateral swollen eyelids with purulent discharge? Improved? Reassure mother No Treat for gonorrhoea and chlamydia Treat mother and partner(s) for gonorrhoea and chlamydia Educate mother Counsel mother Advise to return in 3 days Neonatal conjunctivitis Yes No Reassure mother Advise to return if necessary Refer Figure 10